Provider Demographics
NPI:1265670327
Name:KEINATH, CHARLES R
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:R
Last Name:KEINATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 HIGUERA RD
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-9601
Mailing Address - Country:US
Mailing Address - Phone:802-479-1759
Mailing Address - Fax:
Practice Address - Street 1:80247 91759 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602
Practice Address - Country:US
Practice Address - Phone:802-479-1759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000011101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)